**Policy No.:** BM00026195LI12A

**Date:** June 5, 2012

**THE BERMUDA SHORTS FORM DECLARATIONS (cont'd)**

**Item 8.**
- **a) Premium:**
  - Gross: USD 236,385 part of USD 630,360
  - Net: USD 236,385
- **b) Minimum Earned Premium:** 0%
- **c) Commission:** 0%

**Item 9.**
- **The Company:** XL Insurance (Bermuda) Ltd
  - XL House
  - One Bermudiana Road
  - P.O. Box HM 2245
  - Hamilton HM JX
  - Bermuda
  - Facsimile: (441) 292 1566

**Item 10.**
- **Policy Form:** The Bermuda Shorts Form - 02 (Ed. 07/09)

**Endorsements at Policy Issuance:**
- End. No. 1. Schedule of Excess Policies (XSBSF-001.02)
- End. No. 2. Following Form Policy Endorsement (XSBSF-030.01.01)
- End. No. 3. Several Liability Notice Endorsement (XSBSF-010.01)
- End. No. 4. Follow Form Bermuda Shorts Form Amendatory Endorsement (XSBSF-011.01)
- End. No. 5. Arbitration Endorsement (XSBSF-003.01)
- End. No. 6. Choice of Law Endorsement II (XSBSF-026.01)
- End. No. 7. Assistance and Cooperation Amendment Endorsement (XSBSF-016.01)
- End. No. 8. Cancellation Endorsement - 90 days (XSBSF-052.01)

**IN WITNESS WHEREOF,** this Policy has been made, entered into and executed by the undersigned in Hamilton, Bermuda on this 5th day of June, 2012.

By:
- **Jessica Marwick**
Title: Underwriter

XL XS-BSF-02 (Ed. 07/09)
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